Diabetic kidney disease
In diabetic kidney disease or diabetic nephropathy, cells and blood vessels in the kidneys are damaged, affecting the organs’ ability to filter out waste. Waste builds up in your blood instead of being excreted. In some cases this can lead to kidney failure. When the kidneys fail, a person has to have his or her blood filtered through a machine (a treatment called dialysis) several times a week, or has to get a kidney transplant.
There’s a lot you can do to prevent kidney problems. A recent study shows that controlling your blood glucose can prevent or delay the onset of kidney disease. Keeping your blood pressure under control is also important.
Diabetic kidney disease happens slowly and silently, so you might not feel that anything is wrong until severe problems have developed. Therefore, it is important to get your blood and urine checked for kidney problems each year.
Your doctor can learn how well your kidneys are working by testing every year for microalbumin (a protein) in the urine. Microalbumin in the urine is an early sign of diabetic kidney disease. Your doctor can also do a yearly blood test to measure your kidney function.
To learn more about kidney fuction and diabetic kidney disease click on the following link: About Your Kidneys.docx
Diabetic Eye Disease, or Retinopathy
Diabetic eye disease refers to a group of eye problems that people with diabetes may face as a complication of diabetes. All can cause severe vision loss or even blindness.
Diabetic eye disease may include:
- Diabetic retinopathy—damage to the blood vessels in the retina.
- Cataract—clouding of the eye’s lens. Cataracts develop at an earlier age in people with diabetes.
- Glaucoma—increase in fluid pressure inside the eye that leads to optic nerve damage and loss of vision. A person with diabetes is nearly twice as likely to get glaucoma as other adults.
What is diabetic retinopathy?
Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. It is caused by changes in the blood vessels of the retina.
In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. The retina is the light-sensitive tissue at the back of the eye. A healthy retina is necessary for good vision.
If you have diabetic retinopathy, at first you may not notice changes to your vision. But over time, diabetic retinopathy can get worse and cause vision loss. Diabetic retinopathy usually affects both eyes.
What are the stages of diabetic retinopathy?
Diabetic retinopathy has four stages:
- Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina’s tiny blood vessels.
- Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked.
- Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment.
- Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result.
Causes and Risk Factors
How does diabetic retinopathy cause vision loss?
Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways:
- Fragile, abnormal blood vessels can develop and leak blood into the center of the eye, blurring vision. This is proliferative retinopathy and is the fourth and most advanced stage of the disease.
- Fluid can leak into the center of the macula, the part of the eye where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision. This condition is called macular edema. It can occur at any stage of diabetic retinopathy, although it is more likely to occur as the disease progresses. About half of the people with proliferative retinopathy also have macular edema.
Normal Vision and the same scene viewed by a person with diabetic retinopathy.
Same scene viewed by a person with diabetic retinopathy
Who is at risk for diabetic retinopathy?
All people with diabetes–both type 1 and type 2–are at risk. That’s why everyone with diabetes should get a comprehensive dilated eye exam at least once a year. The longer someone has diabetes, the more likely he or she will get diabetic retinopathy. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. If you have diabetic retinopathy, your doctor can recommend treatment to help prevent its progression.
During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as soon as possible. Your doctor may recommend additional exams during your pregnancy.What can I do to protect my vision?
If you have diabetes get a comprehensive dilated eye exam at least once a year and remember:
- Proliferative retinopathy can develop without symptoms. At this advanced stage, you are at high risk for vision loss.
- Macular edema can develop without symptoms at any of the four stages of diabetic retinopathy.
- You can develop both proliferative retinopathy and macular edema and still see fine. However, you are at high risk for vision loss.
- Your eye care professional can tell if you have macular edema or any stage of diabetic retinopathy. Whether or not you have symptoms, early detection and timely treatment can prevent vision loss.
If you have diabetic retinopathy, you may need an eye exam more often. People with proliferative retinopathy can reduce their risk of blindness by 95 percent with timely treatment and appropriate follow-up care.
The Diabetes Control and Complications Trial (DCCT) showed that better control of blood sugar levels slows the onset and progression of retinopathy. The people with diabetes who kept their blood sugar levels as close to normal as possible also had much less kidney and nerve disease. Better control also reduces the need for sight-saving laser surgery. This level of blood sugar control may not be best for everyone, including some elderly patients, children under age 13, or people with heart disease. Be sure to ask your doctor if such a control program is right for you.
Other studies have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss. Controlling these will help your overall health as well as help protect your vision. For more information about symptoms, detection and treatment of diabetic retinopathy and macular edema, follow this link: http://nei.nih.gov/health/diabetic/retinopathy
This online resource guide provides information about diabetic eye disease. It answers questions about causes and symptoms, and discusses diagnosis and types of treatment. It was adapted from Don’t Lose Sight of Diabetic Eye Disease (NIH Publication No. 04-3252) and Diabetic Retinopathy: What You Should Know (NIH Publication No. 03-2171).
The National Eye Institute (NEI) is part of the National Institutes of Health (NIH) and is the Federal government’s lead agency for vision research that leads to sight-saving treatments and plays a key role in reducing visual impairment and blindness.
Heart Disease and Stroke
What is the connection between diabetes, heart disease, and stroke?
If you have diabetes, you are at least twice as likely as someone who does not have diabetes to have heart disease or a stroke. People with diabetes also tend to develop heart disease or have strokes at an earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest that your chance of having a heart attack is as high as someone without diabetes who has already had one heart attack. Women who have not gone through menopause usually have less risk of heart disease than men of the same age. But women of all ages with diabetes have an increased risk of heart disease because diabetes cancels out the protective effects of being a woman in her child-bearing years.
People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death. High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).
What are the risk factors for heart disease and stroke in people with diabetes?
Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.
You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:
- Having central obesity. Central obesity means carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity. Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol, the type of blood fat that can be deposited on the inside of blood vessel walls.
- Having abnormal blood fat (cholesterol) levels.
- LDL cholesterol can build up inside your blood vessels, leading to narrowing and hardening of your arteries—the blood vessels that carry blood from the heart to the rest of the body. Arteries can then become blocked. Therefore, high levels of LDL cholesterol raise your risk of getting heart disease.
- Triglycerides are another type of blood fat that can raise your risk of heart disease when the levels are high.
- HDL (good) cholesterol removes deposits from inside your blood vessels and takes them to the liver for removal. Low levels of HDL cholesterol increase your risk for heart disease.
- Having high blood pressure. If you have high blood pressure, also called hypertension, your heart must work harder to pump blood. High blood pressure can strain the heart, damage blood vessels, and increase your risk of heart attack, stroke, eye problems, and kidney problems.
Smoking doubles your risk of getting heart disease. Stopping smoking is especially important for people with diabetes because both smoking and diabetes narrow blood vessels. Smoking also increases the risk of other long-term complications, such as eye problems. In addition, smoking can damage the blood vessels in your legs and increase the risk of amputation.
What is metabolic syndrome and how is it linked to heart disease?
Metabolic syndrome is a grouping of traits and medical conditions that puts people at risk for both heart disease and type 2 diabetes. It is defined by the National Cholesterol Education Program as having any three of the following five traits and medical conditions:
Traits and Medical Conditions
Elevated waist circumference
Waist measurement of
Elevated levels of triglycerides
Low levels of HDL (good) cholesterol
Elevated blood pressure levels
Elevated fasting blood glucose levels
Source: Grundy SM, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735–2752.
What can I do to prevent or delay heart disease and stroke?
Even if you are at high risk for heart disease and stroke, you can help keep your heart and blood vessels healthy. You can do so by taking the following steps:
- Make sure that your diet is "heart-healthy." Meet with a registered dietitian to plan a diet that meets these goals:
- Include at least 14 grams of fiber daily for every 1,000 calories consumed. Foods high in fiber may help lower blood cholesterol. Oat bran, oatmeal, whole-grain breads and cereals, dried beans and peas (such as kidney beans, pinto beans, and black-eyed peas), fruits, and vegetables are all good sources of fiber. Increase the amount of fiber in your diet gradually to avoid digestive problems.
- Cut down on saturated fat. It raises your blood cholesterol level. Saturated fat is found in meats, poultry skin, butter, dairy products with fat, shortening, lard, and tropical oils such as palm and coconut oil. Your dietitian can figure out how many grams of saturated fat should be your daily maximum amount.
- Keep the cholesterol in your diet to less than 300 milligrams a day. Cholesterol is found in meat, dairy products, and eggs.
- Keep the amount of trans fat in your diet to a minimum. It's a type of fat in foods that raises blood cholesterol. Limit your intake of crackers, cookies, snack foods, commercially prepared baked goods, cake mixes, microwave popcorn, fried foods, salad dressings, and other foods made with partially hydrogenated oil. In addition, some kinds of vegetable shortening and margarines have trans fat. Check for trans fat in the Nutrition Facts section on the food package.
- If you smoke, quit. Your doctor can help you find ways to quit smoking.
- Ask your doctor whether you should take aspirin. Studies have shown that taking a low dose of aspirin every day can help reduce the risk of heart disease and stroke. However, aspirin is not safe for everyone. Your doctor can tell you whether taking aspirin is right for you and exactly how much to take.
- Get prompt treatment for transient ischemic attacks (TIAs). Early treatment for TIAs, sometimes called mini-strokes, may help prevent or delay a future stroke. Signs of a TIA are sudden weakness, loss of balance, numbness, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache.
How will I know whether my diabetes treatment is working?
You can keep track of the ABCs of diabetes to make sure your treatment is working. Talk with your health care provider about the best targets for you.
A stands for A1C (a test that measures blood glucose control). Have an A1C test at least twice a year. It shows your average blood glucose level over the past 3 months. Talk with your doctor about whether you should check your blood glucose at home and how to do it.
- A1C target: below seven percent, unless your docfgor sets a different target.
- Blood glucose targets:
- Before meals: 80 - 130 mg/dl
- 1-2 hours afte the start of the meal: Less than 180 mg/dl
More or less stringent glycemic goals may be appropriate for some people. Goals are individualized based on the duration of diabetes, age, co-existing health conditions and individual patient considerations. Post-meal or postprandial glucose may be targeted if A1C goals are not met despite reaching pre-meal glucose goals. See http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=84160 for more information.
B is for blood pressure. Have it checked at every office visit.
- Blood pressure target: below 140/90 mm Hg, unless your doctor sets a different target.
C is for cholesterol. Have it checked at least once a year with a lipid panel.
- LDL(bad) cholesterol target: under 100 mg/dl
- Triglyceride target: under 150 mg/dl
- HDL (good) cholesterol target:
- For men: above 40 mg/dl
- For women: above 50 mg/dl
Control of the ABCs of diabetes can reduce your risk for heart disease and stroke. If your blood glucose, blood pressure, and cholesterol levels aren't on target, ask your doctor what changes in diet, activity, and medications can help you reach these goals.
What types of heart and blood vessel disease occur in people with diabetes?
Two major types of heart and blood vessel disease, also called cardiovascular disease, are common in people with diabetes: coronary artery disease (CAD) and cerebral vascular disease. People with diabetes are also at risk for heart failure. Narrowing or blockage of the blood vessels in the legs, a condition called peripheral arterial disease, can also occur in people with diabetes.
Coronary Artery Disease
Coronary artery disease, also called ischemic heart disease, is caused by a hardening or thickening of the walls of the blood vessels that go to your heart. Your blood supplies oxygen and other materials your heart needs for normal functioning. If the blood vessels to your heart become narrowed or blocked by fatty deposits, the blood supply is reduced or cut off, resulting in a heart attack.
Cerebral Vascular Disease
Cerebral vascular disease affects blood flow to the brain, leading to strokes and TIAs. It is caused by narrowing, blocking, or hardening of the blood vessels that go to the brain or by high blood pressure.
A stroke results when the blood supply to the brain is suddenly cut off, which can occur when a blood vessel in the brain or neck is blocked or bursts. Brain cells are then deprived of oxygen and die. A stroke can result in problems with speech or vision or can cause weakness or paralysis. Most strokes are caused by fatty deposits or blood clots—jelly-like clumps of blood cells—that narrow or block one of the blood vessels in the brain or neck. A blood clot may stay where it formed or can travel within the body. People with diabetes are at increased risk for strokes caused by blood clots.
A stroke may also be caused by a bleeding blood vessel in the brain. Called an aneurysm, a break in a blood vessel can occur as a result of high blood pressure or a weak spot in a blood vessel wall.
TIAs are caused by a temporary blockage of a blood vessel to the brain. This blockage leads to a brief, sudden change in brain function, such as temporary numbness or weakness on one side of the body. Sudden changes in brain function also can lead to loss of balance, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache. However, most symptoms disappear quickly and permanent damage is unlikely. If symptoms do not resolve in a few minutes, rather than a TIA, the event could be a stroke. The occurrence of a TIA means that a person is at risk for a stroke sometime in the future. See page 3 for more information on risk factors for stroke.
Heart failure is a chronic condition in which the heart cannot pump blood properly—it does not mean that the heart suddenly stops working. Heart failure develops over a period of years, and symptoms can get worse over time. People with diabetes have at least twice the risk of heart failure as other people. One type of heart failure is congestive heart failure, in which fluid builds up inside body tissues. If the buildup is in the lungs, breathing becomes difficult.
Blockage of the blood vessels and high blood glucose levels also can damage heart muscle and cause irregular heart beats. People with damage to heart muscle, a condition called cardiomyopathy, may have no symptoms in the early stages, but later they may experience weakness, shortness of breath, a severe cough, fatigue, and swelling of the legs and feet. Diabetes can also interfere with pain signals normally carried by the nerves, explaining why a person with diabetes may not experience the typical warning signs of a heart attack.
Peripheral Arterial Disease
Another condition related to heart disease and common in people with diabetes is peripheral arterial disease (PAD). With this condition, the blood vessels in the legs are narrowed or blocked by fatty deposits, decreasing blood flow to the legs and feet. PAD increases the chances of a heart attack or stroke occurring. Poor circulation in the legs and feet also raises the risk of amputation. Sometimes people with PAD develop pain in the calf or other parts of the leg when walking, which is relieved by resting for a few minutes.
How will I know whether I have heart disease?
One sign of heart disease is angina, the pain that occurs when a blood vessel to the heart is narrowed and the blood supply is reduced. You may feel pain or discomfort in your chest, shoulders, arms, jaw, or back, especially when you exercise. The pain may go away when you rest or take angina medicine. Angina does not cause permanent damage to the heart muscle, but if you have angina, your chance of having a heart attack increases.
A heart attack occurs when a blood vessel to the heart becomes blocked. With blockage, not enough blood can reach that part of the heart muscle and permanent damage results. During a heart attack, you may have:
- chest pain or discomfort
- pain or discomfort in your arms, back, jaw, neck, or stomach
- shortness of breath
Symptoms may come and go. However, in some people, particularly those with diabetes, symptoms may be mild or absent due to a condition in which the heart rate stays at the same level during exercise, inactivity, stress, or sleep. Also, nerve damage caused by diabetes may result in lack of pain during a heart attack.
Women may not have chest pain but may be more likely to have shortness of breath, nausea, or back and jaw pain. If you have symptoms of a heart attack, call 911 right away. Treatment is most effective if given within an hour of a heart attack. Early treatment can prevent permanent damage to the heart.
Your doctor should check your risk for heart disease and stroke at least once a year by checking your cholesterol and blood pressure levels and asking whether you smoke or have a family history of premature heart disease. The doctor can also check your urine for protein, another risk factor for heart disease. If you are at high risk or have symptoms of heart disease, you may need to undergo further testing.
What are the treatment options for heart disease?
Treatment for heart disease includes meal planning to ensure a heart-healthy diet, physical activity and or medications. Your medical provider will assist you with developing a plan to help you meet your most optimal health. For more information see http://www.nhlbi.nih.gov
Why is foot care important?
Over time, diabetes can cause you to lose feeling in your feet. When you lose feeling in your feet, you may not feel a pebble inside your sock or a blister on your foot, which can lead to cuts and sores. Diabetes also can lower the amount of blood flow in your feet. Numbness and less blood flow in the feet can lead to foot problems.
Foot care is very important for all people with diabetes, but even more so if you have:
- pain or loss of feeling in your feet (numbness, tingling)
- changes in the shape of your feet or toes
- sores, cuts, or ulcers on your feet that do not heal
If you take care of your feet every day, you can lower your chances of losing a toe, foot, or leg. Managing your blood sugar can also help keep your feet healthy.
Work with your health care team to make a diabetes plan that fits your lifestyle and includes foot care. The team may include your doctor, a diabetes educator, a nurse, a foot doctor (podiatrist) and other specialists who can help you manage your diabetes.
1. Check your feet every day.
- Check your feet for cuts, sores, red spots, swelling, and infected toenails. You may have foot problems, but feel no pain in your feet.
- Check your feet each evening when you take off your shoes.
If you have trouble bending over to see your feet, use a mirror to help. You can also ask a family member or caregiver to help you.
2. Wash your feet every day.
- Wash your feet in warm, not hot, water. Do not soak your feet because your skin will get dry.
- Before bathing or showering, test the water to make sure it is not too hot. You can use a thermometer (90° to 95° F is safe) or your elbow to test the water.
- Use talcum powder or cornstarch to keep the skin between your toes dry to prevent infection
3. Keep the skin soft and smooth.
- Rub a thin coat of lotion, cream, or petroleum jelly on the tops and bottoms of your feet.
Do not put lotion or cream between your toes because this might cause an infection.
4. Smooth corns and calluses gently.
- Thick patches of skin called corns or calluses can grow on the feet. If you have corns or calluses, check with your foot doctor about the best way to care for them.
- If your doctor tells you to, use a pumice stone to smooth corns and calluses after bathing or showering. A pumice stone is a type of rock used to smooth the skin. Rub gently, only in one direction, to avoid tearing the skin.
- Do not cut corns and calluses.
Do not use razor blades, corn plasters, or liquid corn and callus removers - they can damage your skin and cause an infection.
5. If you can see, reach, and feel your feet, trim your toenails regularly.
- Trim your toenails with nail clippers after you wash and dry your feet.
- Trim your toenails straight across and smooth the corners with an emery board or nail file. This prevents the nails from growing into the skin. Do not cut into the corners of the toenail.
- Have a foot doctor trim your toenails if:
- you cannot see or feel your feet
- you cannot reach your feet
- your toenails are thick or yellowed
- your nails curve and grow into the skin
6. Wear shoes and socks at all times.
- Wear shoes and socks at all times. Do not walk barefoot when indoors or outside. It is easy to step on something and hurt your feet. You may not feel any pain and not know that you hurt yourself.
- Make sure you wear socks, stockings, or nylons with your shoes to keep from getting blisters and sores.
- Choose clean, lightly padded socks that fit well. Socks that have no seams are best.
- Check inside your shoes before you put them on. Make sure the lining is smooth and that there are no objects in your shoes.
Wear shoes that fit well and protect your feet.
7. Protect your feet from hot and cold.
- Wear shoes at the beach and on hot pavement. You may burn your feet and may not know it.
- Put sunscreen on the top of your feet to prevent sunburn.
- Keep your feet away from heaters and open fires.
- Do not put hot water bottles or heating pads on your feet.
- Wear socks at night if your feet get cold.
Wear lined boots in the winter to keep your feet warm.
8. Keep the blood flowing to your feet.
- Put your feet up when you are sitting.
- Wiggle your toes for 5 minutes, 2 or 3 times a day. Move your ankles up and down and in and out to help blood flow in your feet and legs.
- Do not cross your legs for long periods of time.
- Do not wear tight socks, elastic, or rubber bands around your legs.
Do not smoke. Smoking can lower the amount of blood flow to your feet. Ask for help to stop smoking. Call 1-800-QUITNOW (1-800-784-8669).
9. Be more active.
- Being active improves blood flow to the feet. Ask your health care team for safe ways to be more active each day. Move more by walking, dancing, swimming, or going bike riding.
- If you are not very active, start slowly.
- Find safe places to be active.
Wear athletic shoes that give support and are made for your activity.
10. Be sure to ask your health care team to:
- check your feet at every visit
- check the sense of feeling and pulses in your feet at least once a year
- show you how to care for your feet
- refer you to a foot doctor if needed
Tell you if special shoes would help protect your feet.
11. Take care of your diabetes.
- Work with your health care team to make a plan to manage your diabetes.
- Ask your health care team to help you set and reach goals for managing your blood sugar, blood pressure, and cholesterol.
Ask your team to help you choose safe ways to be more active each day and choose healthy foods to eat.
Tips for Choosing the Right Footwear
Wearing the right type of shoes is important for keeping your feet healthy. Walking shoes and athletic shoes are good for daily wear. They support your feet and allow them to "breathe."
- Never wear vinyl or plastic shoes, because they do not stretch or "breathe."
- When buying shoes, make sure they feel good and have enough room for your toes.
- Do not wear shoes with pointed toes or high heels often. They put too much pressure on your toes.
Buy shoes at the end of the day when your feet are the largest so that you can find the best fit.
Medicare and other insurance for special footwear:
You may need special shoes or shoe inserts to support your feet. Medicare Part B insurance may cover some of the cost of special shoes or inserts. Ask your doctor if your insurance plan will pay for:
- Depth shoes or inserts. Depth shoes look like walking shoes, but have more room in them. The extra room is for different shaped feet and toes, or for inserts made to fit your feet.
- Custom molded shoes with inserts.
Ask your doctor or foot doctor how you can get this special footwear.
Things to remember:
- Set a time every day to check your feet.
- Wear socks and shoes at all times.
- Write down the date of your next visit to the doctor. Go to all of your appointments and ask any questions that you have.
- Set a date for getting the things you need to take care of your feet: nail clippers, pumice stone, emery board, skin lotion, talcum powder, plastic mirror, socks, walking shoes, and slippers.
- If you smoke, stop smoking.
- Manage your diabetes so you can prevent foot problems.
To learn more:
National Diabetes Education Program 1-888-693-NDEP (1-888-693-6337) www.YourDiabetesInfo.org
American Association of Diabetes Educators 1-800-338-3633 www.diabeteseducator.org
American Diabetes Association 1-800-DIABETES (1-800-342-2383) www.diabetes.org
American Podiatric Medical Association (APMA) 301-581-9200 www.apma.org
Centers for Disease Control and Prevention 1-800-CDC-INFO (1-800-232-4636) www.cdc.gov/diabetes
Centers for Medicare & Medicaid Services 1-800-MEDICARE (1-800-633-4227) http://www.medicare.gov/coverage/therapeutic-shoes-or-inserts.html
National Institute of Diabetes and Digestive and Kidney Diseases National Diabetes Information Clearinghouse 1-800-860-8747 www.diabetes.niddk.nih.gov